Liberty Healthcare report on the Oregon State Hospital – DRAFT, September 2010 (Full Text PDF)
Introduction & Summary
Review Team & Methodology
Part 1, Staff Compliance vs. Quality Management
Part 2, Leadership
Part 3, Decisive Authority
Part 4, Diffusion
Part 5, HIG and the Role of Quality Management
Part 6, Prime Causes of Overtime
Part 7, Improving Personnel Management
Report Attachments A through F
Part 3. Decisive Authority – Need for clear and decisive authority
Summary: Combined with the actual and perceived absence of hospital leadership on the units, the lines of authority for decision-making are confused and unclear. Staff at all levels appear hampered by uncertainty about who is in charge and who is making decisions with regard to different functions. Accountability is vague. For example, clinical supervisors believe that HR prevents them from disciplining under-performing employees and look to HR to tell them what to do. HR believes that the managers know what to do but want HR to make the decisions regarding discipline, which is not a HR but a management function. Although recent directives have established the mechanism of having clinicians supervise clinicians within their own discipline, there is still need for clarification on cross-disciplinary supervision and lines of authority. For example, security personnel are given full authority to manage volatile situations within the units, which reflects a correctional/control approach rather than a therapeutic response to challenging behavior. This model for handling disruptive behavior greatly raises the liability and risk of injury. There should be no question that OSH is a treatment facility. It is imperative that senior clinical staff must guide the decision-making in these situations. Security staff should not take any independent action in the resolution of behavior problems within the therapeutic interior of the program. They should be working under the direction of RN supervision at the scene of the incident. There is a serious lack of cohesive teamwork between the Clinical Departments and the Health Information Group (HIG). The perception of the clinical group is that a lot of data is collected, but that little is done with it. They complain of not getting feedback information and analysis in a form that can be readily and directly applied to practice. The quality group, in turn, complains that the clinical group discounts or disregards the findings and feedback by “explaining away” the findings as artifacts and attacking the data as faulty and unreliable. Neither group has the authority to make decisions or enforce compliance. The Forensics Service, in particular, is a huge service and the scope of work is intensive. There are currently three Nurse Program Managers divided among the 14 wards of the Forensics Service, which are now directed by the newly implemented Unit Nurse Manager role. This strain is exacerbated by the fact that the new Unit Shift Supervisor positions, which will report to the Unit Nurse Managers and assume some of the current job duties, have yet to be implemented.
Recommendations:
A 3.1. – Reduce Cabinet size for effectiveness: The 14-member Cabinet is simply too large and unwieldy to be an effective executive decision-making team for a psychiatric hospital. We recommend reducing the Cabinet to a tight executive team of 5-7 managers, such as the Superintendent, Clinical Director, Medical Director, Chief Financial Officer, Chief Nursing Officer, HR Director and Quality Management Director.
A 3.2. – Streamline the number of Committees for effectiveness: As described in detail in the next section, the Liberty Review Team recommends a major restructuring and consolidation of committees, subcommittees and performance improvement teams that will reduce the number of committees, simplify lines of authority and accountability, and free professional staff to focus more on the delivery of care.
A 3.3. – Enhance support for Unit Nurse Managers: The Unit Nurse Managers are confused, anxious and overwhelmed by the changeover of administrative/clinical structure at the unit level. They need greater support to take full authority in their new role. In addition, the Unit Shift Supervisors must be given the support and training needed to fulfill their role in dealing with work performance issues. The Unit Nurse Managers are still learning the scope and range of their authority and most need stronger personnel management skills to apply their authority. There is a lack of interaction between the MHTs and RNs on many of the Forensic units. On some of the units there is conflict between the RNs and the MHTs about who is in charge. This conflict must be addressed in order for the units to stabilize and patients to receive the best care possible. OSH needs to enhance support for the Unit Nurse Managers by:
A 3.3.a – Strong presence of Program Nurse Managers on units: The Nurse Program Managers must provide strong and frequent on-site support to the Unit Nurse Managers by mentoring them for leadership, directly observing the work load and challenges on the units, and facilitating support from HR in managing personnel problems. It is imperative that the Program Nurse Manager have a strong working knowledge of the Union contract and HR rules/regulations regarding employee disciplinary actions. The Program Nurse Manager should be facilitating the movement of actions through the HR Department. A frequent presence on the unit will allow the Program Nurse Manager, the Unit Nurse Manager and eventually the Shift Supervisor to clarify expected duties and responsibilities and to potentially modify the job or systems accordingly. The issue of MHT/RN control of the unit must be addressed at all levels of the organization (Cabinet to MHTs). Once the problem is clearly identified, a determination must be made as to whether the problem is specific to a unit or systemic requiring a more formalized action plan. The Program Nurse Manager should also support the Unit Nurse Manager in working with individual MHTs. It is important that the role of the MHT is respected within the organization.
A 3.3.b. – Personnel management skills training: The HR Department does offer a two-day course for new supervising managers but given the pervasive manager view that HR prevents them from taking corrective action with problem employees, the Team questions the overall value of this course in dealing with performance issues. OSH needs to establish annual refresher training for Unit Nurse Managers and Program Nurse Managers (and possibly the Clinical Chiefs) in performance management techniques for managing problematic employees. This training will also need to include strategies geared toward helping employees to improve in their performance and become successful.
A 3.3.c. – Designated personnel management support consultant: The HR Department should designate a HR expert in performance management, job performance appraisal and disciplinary actions to provide intensive consultative support to the Program Nurse Managers and the Unit Nurse Managers. (This should include the Unit Shift Supervisors when they are hired since they will be evaluating work performance and completing the work appraisals for nursing staff on their shift). Given that HR is minimally staffed and have a couple of positions frozen, this recommendation may necessitate the hiring of an additional HR position that could be dedicated to assisting nursing managers and shift supervisors.
A 3.3.d. – Designated labor relations consultant: OSH should consider hiring a fulltime labor relations expert to serve as a liaison between hospital management, HR and the unions to provide on-going advice, support and problem-solving as needed. This position can help navigate and mitigate the perceived intimidation and learned helplessness of managers and supervisors in handling problematic union employees for fear of conflict.
A 3.4. – Personnel skills for other clinical supervisors: In addition to the Unit Nurse Managers, all other clinical supervisors need support and training to work within the system to deal with staff performance issues in a timely and effective manner. There is a pervasive belief among clinical managers that they can do little to discipline and remove problem employees and that this is the domain of HR. HR is very clear that supervision is a management responsibility, not an HR function. HR expects the clinical supervisors to discipline their own staff. The Liberty Review team recommends both the addition of refresher training and the establishment of a designated personnel management position or “hot line” to provide immediate consultative assistance to supervisors in responding to complex personnel issues.
A 3.5. – Clarify authority structure of new unit supervision model: OSH is in the process of introducing a new model of unit supervision that calls for shared responsibility between the Unit Nurse Manager, Treatment Care Plan Specialist and the Unit Shift Supervisor. This model is untested and the Liberty Review Team has concerns that this “co-leadership” model could be another way that authority will become diffused and potentially undermine decisive leadership at the unit level.
A 3.5.a. – Put Unit Nurse Manager in clear command: We recommend that the Nurse Manager should be the position with clear unit director authority. The Unit Shift Supervisor will be directly reporting to the Unit Nurse Manager, but the Treatment Care Plan Specialist reports to the Associate Director of Clinical Services. There could also be some conflict or role delineation issues/questions between the Unit Nurse Manager and the new Treatment Care Plan Specialist positions because some of these individuals had previously held the authority of Unit Directors. There is also some risk of confusion between the Unit Nurse Manager and the Unit Shift Supervisor roles because the Unit Shift Supervisor has the responsibility for evaluating the staff on his/her assigned shift.
A 3.6. – Strengthen inter-shift linkages: Although the treatment malls have been a resounding success at OSH, the new model has created a new challenge to be addressed. Given that staff is now frequently “off unit” to supervise/escort patients to and from the treatment malls, there is a need for a stronger mechanism for inter-shift reporting/transfer of information, especially on the Forensic Units where some units send patients to two different malls. Shift reports are critical to the continuity of patient care and safety. At present, the Unit Nurse Managers feel that they can accomplish little more than read the shift report and they are unable to share specific patient information with the on-coming shift. This important concern was frequently voiced during the Unit visits and in the meetings with the Nurse Executive Committee, Program Nurse Managers and Unit Nurse Managers. The Liberty Review Team recommends that nursing should work with Dr. McLoughlin, the Nursing Consultant for CRIPA issues, to determine how to resolve this dilemma.
A 3.7. – Clinical staffing schedules need to meet organization’s needs: The use of four-day work week schedules for some psychiatrists and psychologists has had some negative impact on the fulfillment of clinical functions, participation in interdisciplinary team planning and continuity of care. Specifically, about half of the Psychologists and many of the psychiatrists work four 10-hour days per week. The needs of the hospital must supersede the needs of the individual clinicians. The Review Team recommends a critical reexamination of the scheduling practices.
A 3.8. – Need to enforce documentation: It is notable that the OSH policy calling for the standardization of documentation around progress notes is still not in effect as of 7/15/10. Lack of documentation was highlighted as a major issue at OSH shortly after the patient death in October 2009. Auditing and identification of deficiencies may be a quality function, but enforcement of a fundamental policy is the responsibility of the clinical leadership. The clinical leadership must promptly address this compliance issue.